Semantic search
Jump to navigation
Jump to search
| Start date | Reporting criterion | Title | Event description | System | LER | |
|---|---|---|---|---|---|---|
| ENS 46981 | 24 June 2009 04:00:00 | Agreement State | Agreement State Report - Patient Injected with Wrong Isotope | The following information was obtained from New York City via email: On 6/24/09, a patient was brought to the Nuclear Medicine Department for a myocardial viability exam and was to be injected with Thallium-201. The Nuclear Medicine Technologist instead injected the patient with Gallium-67 and immediately realized his mistake. The Gallium vial was right next to the Thallium vial in the storage case. The Head of Nuclear Medicine was informed. He then explained the situation to the patient and advised the patient to take a mild laxative to reduce radiation dose to the large intestine. The event was documented in the patient's chart, and the referring physician was informed. Consequences: The estimated absorbed total body dose was 0.5200 rads and the dose to the liver was estimated at 1.2600 rads. The viability study was rescheduled. Corrective actions taken: The Policy and Procedures Manual was revised to include specific instructions about double checking that the correct radioisotope was being chosen; training was conducted by the Radiation Safety Officer; and a sign was posted in the lab listing the steps that must be observed before injecting any patient with radioisotopes. An inspection was conducted by the Office of Radiological Health on 7/16/09 and the inspector found that the licensee had made a timely report to the (New York City Bureau of Radiation Health (NYCBRH)), and the corrective actions taken were appropriate and effective. This case has been closed by the NYCBRH. A Medical Event may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |